I hereby authorize Gradient Insurance Brokerage, Inc. to complete contracting requirements with only the companies I have checked above. I understand that I may receive a copy of the entire contract upon request. I also understand that I must send the unique signature page for my contracting to be valid.

Background Information

Yes
No

1. Have you ever been charged, convicted, or plead no contest to any crime or are there criminal charges pending against you or a business with which you are connected?
Please indicate if
MISDEMEANOR and/or FELONY.

Yes
No

2. Have you had, or do you currently have any outstanding collection accounts, judgments, liens, or garnishments against you or a business of which you were or presently are a principal? If yes, please provide the date of lien, initial amount, current amount and the payment amount on following page.

Yes
No

3. Have you ever been a party to or have you personally violated any securities or commodities law or rule set by any securities or commodities regulatory body, organization, or employer in the commodities or insurance industry?

Yes
No

4. Do you owe money to any insurance company, agency, manager or broker dealer, or have any business or personal debts that resulted in collections or charge-­offs?

Yes
No

5. Have you or a firm in which you were a partner, officer, or director filed for protection from creditors, been declared bankrupt or insolvent, been a party to bankruptcy or receivership proceeding, compromised liabilities with creditors, or had a direct payment procedure initiated under the Securities Investor Protection Act?
Please indicate Chapter:
7,
11,
13
and the discharge date:

Yes
No

6. Have you ever defaulted on a promissory note, or any other debt, including consumer or credit card debt?

Yes
No

7. Have you ever been bonded?

Yes
No

8. Are you currently bonded?

Yes
No

9. Has a bonding or surety company ever denied, refused, paid out on, canceled, revoked or refused to continue a bond for you?

Yes
No

10. If there any reason you cannot secure a bond?

Yes
No

11. Has any insurance department, securities broker-­‐dealer, government agency, or self-­‐regulatory authority ever denied, suspended, revoked, censured, barred your license (as an insurance agent, attorney, accountant, or federal contractor) or registration, disciplined you with fines, entered an order against you, restricted your activities, canceled any contract or appointment with you or any other member, partner, officer or controlling persons in your organization or is there any pending disciplinary action?
Please indicate if
DENIED
SUSPENDED
REVOKED
CENSURED or
BARRED.

Yes
No

12. Have you ever had a claim filed against your Professional Liability or Errors and Omissions insurance coverage or has any E&O Carrier denied, paid claims on, or canceled your coverage?

Yes
No

13. Have you had any complaints or deficiency claims filed against you by any insured/annuitant with any insurance company or state insurance department in the past 10 years?

Yes
No

14. Have you ever used any other names or aliases on a license or other registration?

Yes
No

15. Are you now or have you ever been employed by, or associated with to any degree directly or indirectly, a bank, savings and loan, or other financial institution?

Yes
No

16. Are you now subject to any complaint, investigation, or proceeding which could result in a yes answer to any of the proceeding questions?

I have read the questions above and have answered them to the best of my knowledge.

Material Review Agreement

This Confidential Information Acknowledgment (the “Agreement”) is made effective, as of the date listed below, by and between Gradient Insurance Brokerage, Inc. (the “Company”)1 and the undersigned Financial Services Professional (“FSP”).
FSP acknowledges and agrees to the following:

This Agreement shall remain in effect indefinitely. FSP understands and acknowledges that unauthorized use or disclosure of any Confidential Information will cause irreparable damage to the Company, and FSP acknowledges that the Company may seek and obtain injunctive relief against the breach – or threatened breach – of the disclosure of any Confidential Information by FSP in addition to any other legal remedies that may be available.

I hereby acknowledge and consent to the statements as expressed above.

Privacy Policy and Consent

Gradient Insurance Brokerage, Inc. (“Company”)1 employs physical, electronic and procedural controls in order to protect confidential information. Company may use personal information about you to assist Company in placing you with an annuity or life insurance company. Company will always restrict access to personal information to those who require it to provide products or services to you or to complete contracting requirements with certain annuity and life insurance companies. The only time Company will provide any information about you or your financial information is in these limited situations:

To complete transactions or account changes, as directed by you

To maintain or service your account

If requested by you

With entities under common ownership and control of Company

If Company is required or permitted by law or regulatory authorities with jurisdiction over Company

Again, your privacy is important. Company is dedicated to safeguarding your personal and financial information. Company maintains physical, electronic, and procedural safeguards to comply with federal standards to guard your confidential personal information.
Further, Company takes and records photos and videos during Company sponsored events. I hereby consent to the use of any such photo or video containing my image or likeness for Company’s own promotional or marketing needs.
I hereby acknowledge and consent to the statements as expressed above.1For the purposes of this Agreement, the term “Company” shall refer to Gradient Insurance Brokerage, Inc., along with any person or entity that directly or indirectly controls, is controlled by, is under common control with, or is associated through constructive ownership with the Company. The term “Company” shall also expressly include Gradient Financial Group, LLC and its contracted member companies.